Multiple Sclerosis

Case #342: MRI Brain and C-spine, 12/20/93: Multiple sclerosis.

CC: Numbness.

Hx: This 23y/o RHF initially presented to a local physician in 5/93 with complaints of diffuse pain, fatigue and numbness of her RUE and RLE. She underwent two lumbar punctures and two MRI scans, the results of which are not known. She stated she had "lymphocytes" in her CSF and was treated with an IV steroid; followed by an oral steroid. Her symptoms spontaneously resolved in late 7/93. One month prior to this presentation, she experienced recurrent fatigue and a "heavy" felling in BUE and BLE. One week ago she experienced "spasms" of BUE and a 2 day episode of horizontal binocular diplopia. During the past week she has noticed increased fatigue, and heaviness of her limbs. Her symptoms worsen following hot showers.

She underwent a lumbar puncture on 12/17/93 and CSF analysis yielded: Protein 42(normal 15-45mg.dl), Glucose 48, RBC 0, WBC 15(13 lymphocytes, 2 histiocytes), IgG 2.6mg/dl(normal), IgG index 0.5(normal), No oligoclonal bands were found. CBC and Lyme titers were normal. Urinalysis revealed 1-2 WBC and leukoesterase positivity. She was given a 3 day course of Bactrim and returned 12/20/93 for MRI scan and possibly steroid treatment.

MEDS: Bactrim.

PMH: unremarkable.

FHX: unremarkable.

SHX: raised in Illinois. Currently a student. Denies tobacco/ETOH/illicit drug use.

EXAM: BP116/54 HR76 RR18 Afebrile.

MS: unremarkable. Normal speech without dysarthria.

CN: No RAPD or INO. VFFTC, Pupils 4/4 decreasing to 2/2 on light exposure. The rest of the CN exam was unremarkable.

Motor: Full strength throughout with exception of 5- strength in distal LUE.

Sensory: Decreased PP and LT from a T8 level on the right side.

Coord: Poor HKS in BLE. Slowed RAM and FNF in the RUE.

Station: unsteady with and without eyes open on Romberg testing.

Gait: mildly spastic and had difficulty with TW.

Reflexes: 3/3+biceps,triceps, brachioradialis. 3+/3+ quadriceps and 4/4 archilles with sustained ankle clonus, bilaterally. Plantar responses were equivocal, bilaterally.

Gen Exam: unremarkable.

COURSE: MRI Brain and C-spine on 12/20/93 revealed increased signal on T2 weighted images in the lower medulla and postrior aspect of the spinal cord at the C1 level.

She was treated with a 3 day course of IV Solumedrol; followed by a Prednisone taper. Her symptoms gradually improved in the 2 weeks following treatment. She went on to have a relapsing-remitting course with admissions in 12/94, 3/95, 6/95, 7/95, and 12/95. She was offered Avonex( Beta Interferon 1A) but did not initiate treatment right away due to financial reasons. During her 12/95 hospitalization she had marked right hemiparesis and spaticity. She had been taking Baclofen for the later for several months prior to 12/95. She is currently disabled.